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Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections

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Abstract

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Background

Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries.

Objectives

To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2009).

Selection criteria

We included randomized trials assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post‐cesarean infectious morbidity.

Data collection and analysis

We independently assessed eligibility and quality of the studies.

Main results

Four trials (involving 1361 randomized and 1198 analyzed women) evaluated the effects of vaginal cleansing (all with povidone‐iodine) on post‐cesarean infectious morbidity. The risk of bias was generally low, with the quality of most of the studies being high. Vaginal preparation immediately before cesarean delivery significantly reduced the incidence of post‐cesarean endometritis from 9.4% in control groups to 5.2% in vaginal cleansing groups (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.38 to 0.87, four trials, 1198 women). The risk reduction was particularly strong for women with ruptured membranes (1.4% in the vaginal cleansing group versus 15.4% in the control group; RR 0.13, 95% CI 0.02 to 0.66, two trials, 148 women). No other outcomes realized statistically significant differences between the vaginal cleansing and control groups. No adverse effects were reported with the povidone‐iodine vaginal cleansing.

Authors' conclusions

Vaginal preparation with povidone‐iodine solution immediately before cesarean delivery reduces the risk of postoperative endometritis. This benefit is particularly realized for women undergoing cesarean delivery with ruptured membranes. As a simple, generally inexpensive intervention, providers should consider implementing preoperative vaginal cleansing with povidone‐iodine before performing cesarean deliveries.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

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Vaginal cleansing before cesarean delivery to reduce post‐cesarean infections

Cesarean deliveries are very common today, with almost one in three babies born by cesarean in some countries. Antibiotics are routinely given before or during the surgery to reduce the risk of infections, but some women still suffer from these complications. Between one in four and one in 10 women develop an infection of the uterus (endometritis) or a problem with their skin incision, respectively. These complications slow recovery from the surgery and may affect the mother's ability to take care of her baby. Other interventions are needed to further reduce the risk of infections of the uterus and wound problems after cesarean delivery.

This review found that cleansing the vagina with an antiseptic solution immediately before the cesarean delivery reduced the risk of post‐cesarean infection of the uterus (womb). The benefit was greater if the woman's water had already broken (the membranes had ruptured). This review did not find that vaginal cleansing reduced the number of women experiencing fever or wound complications after cesarean delivery. The antiseptic was povidone‐iodine, and no adverse events such as allergy or irritation were noted in any of the four randomized trials, reporting on 1198 women, from vaginal preparation solution.